Authorization and Notification Requirements - Effective January 1, 2026
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Lists services that require prior authorization or notification for UCare plans serving Minnesota populations and explains submission and timing expectations for providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Medical Necessity Sources
inv-01: Acute inpatient hospitalization — medical necessity criteria referencing tools
Acute inpatient services covered when medical necessity criteria met as defined by referenced tools
inv-02: Back (spine) surgery criteria — InterQual or referenced criteria
Back (spine) surgery covered when InterQual or referenced criteria met
InterQual Medicare Procedures and InterQual CP Procedures referenced for criteria
inv-03: DME and EIDBI — coverage contingent on item/program-specific InterQual or MHCP criteria
DME and EIDBI coverage contingent on item/program-specific InterQual or MHCP criteria
inv-04: DME medical necessity criteria sources — referenced medical necessity sources for DME
Medical necessity references for DME and certain services
inv-05: Spinal Cord Stimulation criteria sources
Spinal cord stimulation medical necessity
Prior authorization required for trial and permanent placement
inv-06: Proton Beam Therapy criteria sources
Proton beam therapy criteria
Prior authorization required
inv-07: Transplant criteria source — medical necessity source
Transplant medical necessity source
Applies to listed transplant types
inv-08: Transplant notification and medical necessity — notification requirements
Notification requirements for transplant admissions
Applies to Heart, Heart/Lung, Hematopoietic Stem Cell, Liver, Lung, Pancreas, Pancreas/Kidney, Pancreatic Islet Cell, Small Bowel, Small Bowel/Liver
inv-09: Vein procedures — authorization requirement
Vein procedures authorization
Applies across plan types as indicated
inv-10: Wheelchairs and accessories — DME authorization for wheelchairs and accessories
Durable medical equipment (wheelchairs and accessories) authorization
UCare reserves right to determine rental vs purchase
UCare reserves right to determine rental vs purchase
Authorization is not required for breast reconstruction associated with breast cancer. Cosmetic and reconstructive procedures generally require prior authorization prior to service, but this specific exception is noted in the policy and does not require an authorization request.
Authorization is not required for formula or nutritional services administered through a feeding tube. Formula or nutritional products delivered by enteral feeding do not require prior authorization, whereas formula and nutritional services delivered by other routes remain subject to the usual prior authorization and medical necessity criteria.
No additional coverage exceptions are listed in the provided sections for this item.
No entries for non-covered (not medically necessary) services are specified in the provided excerpts.
Codes and Billing Thresholds
| H2012 | Community Psychiatric Support – Day Treatment |
| H0019 | Intensive Residential Treatment Services |
| Rev 0172 | NICU revenue code |
| 0173 | NICU revenue code |
| 0174 | NICU revenue code |
| E0986 | Wheelchair accessory/equipment |
| E1002 | Wheelchair accessory/equipment |
| E1003 | Wheelchair accessory/equipment |
| E1004 | Wheelchair accessory/equipment |
| E1005 | Wheelchair accessory/equipment |
| E1006 | Wheelchair accessory/equipment |
| E1007 | Wheelchair accessory/equipment |
| E1008 | Wheelchair accessory/equipment |
| E1009 | Wheelchair accessory/equipment |
| E1010 | Wheelchair accessory/equipment |
| K0800 | Power wheelchair / mobility device |
| K0801 | Power wheelchair / mobility device |
| K0802 | Power wheelchair /mobility device |
| K0806 | Power wheelchair / mobility device |
| K0807 | Power wheelchair /mobility device |
| K0808 | Power wheelchair / mobility device |
| K0813 | Power wheelchair / mobility device |
| K0814 | Power wheelchair / mobility device |
| K0815 | Power wheelchair / mobility device |
| K0816 | Power wheelchair / mobility device |
Provider Requirements: Prior Authorization, Notifications, and Documentation
Proton Beam Therapy — Prior Authorization Required
Prior authorization is required prior to service for Proton Beam Therapy (PBRT). Submit a completed authorization request with supporting clinical documentation by fax or email as noted on the applicable UCare request form. PA does not guarantee payment.
- Proton Beam Therapy — prior authorization required prior to service
- Submit request form with clinical documentation by fax or email per UCare instructions
Spinal Cord Stimulation — Prior Authorization Required
Prior authorization is required prior to trial and prior to permanent placement of spinal cord stimulation devices. Provide clinical documentation supporting medical necessity with the authorization request.
- SCS trial and permanent placement — prior authorization required prior to each
- Include supporting clinical documentation when submitting authorization request
Vein Procedures — Prior Authorization Required
Prior authorization is required prior to performing vein procedures. Providers must submit the appropriate authorization request and supporting clinical documentation; failure to obtain prior authorization may result in denial.
- Vein procedures — prior authorization required prior to service
- Submit request form with clinical documentation by fax or email per UCare instructions
- Risk of denial if performed without prior authorization
Formula / Nutritional Services — Prior Authorization Required
Formula and nutritional services require prior authorization prior to service except when administered through a feeding tube. Submit the authorization request with clinical documentation referencing enteral/parenteral nutrition criteria.
- Formula or Nutritional Services — prior authorization required prior to service
- Authorization not required if administered through a feeding tube
- Include clinical documentation supporting need and type of formula/product
SUD Outpatient Thresholds — Prior Authorization Required
Substance Use Disorder (SUD) outpatient treatment exceeding specified daily or weekly thresholds requires prior authorization. Hours are calculated on a rolling seven-day period; authorizations may be issued for up to 28 days.
- SUD outpatient — prior authorization required when treatment exceeds 6 hours per day or 30 hours per week
- Hours calculated in a rolling seven-day span
- Authorizations can be given for up to a 28-day time span
Occupational Therapy — Authorization Threshold
Occupational therapy services require prior authorization once the threshold of visits per calendar year is exceeded. Submit an authorization request with supporting documentation when thresholds are met.
- OT — prior authorization required after 24 visits per calendar year
- Include clinical documentation supporting continued medical necessity
Physical Therapy — Authorization Threshold
Physical therapy services require prior authorization once the threshold of visits per calendar year is exceeded. Submit an authorization request with supporting documentation when thresholds are met.
- PT — prior authorization required after 14 visits per calendar year
- Include clinical documentation supporting continued medical necessity
Submission and Documentation — How to Request Authorization / Notify
To request prior authorization or submit required notifications, complete the appropriate UCare request form and include all supporting clinical documentation. Send requests and documentation by fax or email to the addresses listed on the request form. Allow up to seven calendar days for non-urgent authorization decisions. Failure to obtain required authorization prior to service may result in claim denial.
- Submit the correct request form with supporting clinical documentation by fax or email as listed on each form
- Allow up to seven calendar days for non-urgent authorization decisions
- Failure to obtain prior authorization when required may result in denial
Policy Background and Scope
This policy enumerates administrative prior authorization and notification requirements across inpatient, outpatient, procedural, behavioral health, and durable medical equipment services. Providers must follow listed prior authorization requirements and timeframes and submit supporting clinical documentation on the appropriate request form by the methods listed on each form.
When medical necessity determinations are required, the policy references InterQual criteria and the Minnesota Health Care Programs Provider Manual where applicable; UCare or its delegates perform clinical review to determine whether requests meet those criteria.
Certain inpatient events require notification to UCare within specified timeframes (for example, notify UCare within 24 hours of admission for listed transplant procedures). Failure to obtain required prior authorization or timely notification may result in claim denial or impact claim processing.
For inpatient admissions that do require review, UCare will contact facilities when concurrent review is required and expects discharge summaries to be sent according to the timelines in the policy (for example, discharge summaries for inpatient admissions are required within 72 hours of discharge).
Definitions
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